Mental health disorders are leading causes of

morbidity, disability and mortality in the United

States (1). In the general, U.S. population, approx-
imately 46% of people, will meet the criteria for a
mental health disorder at some point in their
lifetime, and half of all lifetime cases occur by
mid-adolescence (2). Of these lifetime disorders,
approximately 17% of people will have a major
depressive disorder and 29% will have an anxiety
disorder (2). Comparatively, the 12-month preva-
Community Dent Oral Epidemiol 2012; 40: 134144
All rights reserved
2011 John Wiley & Sons A/S
The association between
depression and anxiety and use
of oral health services and tooth
loss
Okoro CA, Strine TW, Eke PI, Dhingra SS, Balluz LS. The association between
depression andanxiety anduse of oral health services andtooth loss. Community
Dent Oral Epidemiol 2012; 40: 134144. 2011 John Wiley & Sons A S
Abstract Objective: The purpose of this study is to examine the associations
among depression, anxiety, use of oral health services, and tooth loss.
Methods: Data were analysed for 80 486 noninstitutionalized adults in 16 states
who participated in the 2008 Behavioral Risk Factor Surveillance System.
Binomial and multinomial logistic regression analyses were used to estimate
predicted marginals, adjusted prevalence ratios, adjusted odds ratios (AOR)
and their 95% condence intervals (CI). Results: The unadjusted prevalence for
use of oral health services in the past year was 73.1% [standard error (SE), 0.3%].
The unadjusted prevalence by level of tooth loss was 56.1% (SE, 0.4%) for no
tooth loss, 29.6% (SE, 0.3%) for 15 missing teeth, 9.7% (SE, 0.2%) for 631
missing teeth and 4.6% (SE, 0.1%) for total tooth loss. Adults with current
depression had a signicantly higher prevalence of nonuse of oral health
services in the past year than those without this disorder (P < 0.001), after
adjustment for age, sex, race ethnicity, education, marital status, employment
status, adverse health behaviours, chronic conditions, body mass index,
assistive technology use and perceived social support. In logistic regression
analyses employing tooth loss as a dichotomous outcome (0 versus 1) and as a
nominal outcome (0 versus 15, 631, or all), adults with depression and anxiety
were more likely to have tooth loss. Adults with current depression, lifetime
diagnosed depression and lifetime diagnosed anxiety were signicantly more
likely to have had at least one tooth removed than those without each of these
disorders (P < 0.001 for all), after fully adjusting for evaluated confounders
(including use of oral health services). The adjusted odds of being in the 15
teeth removed, 631 teeth removed, or all teeth removed categories versus 0
teeth removed category were increased for adults with current depression
versus those without (AOR = 1.35; 95% CI = 1.141.59; AOR = 1.83; 95%
CI = 1.512.22; and AOR = 1.44; 95% CI = 1.111.86, respectively). The adjusted
odds of being in the 15 teeth removed and 631 teeth removed categories
versus 0 teeth removed category were also increased for adults with lifetime
diagnosed depression or anxiety versus those without each of these disorders.
Conclusion: Use of oral health services and tooth loss was associated with
depression and anxiety after controlling for multiple confounders.
Catherine A. Okoro
1
, Tara W. Strine
1
,
Paul I. Eke
2
, Satvinder S. Dhingra
1
and
Lina S. Balluz
1
1
Division of Behavioral Surveillance, Public
Health Surveillance Program Ofce, Ofce of
Surveillance, Epidemiology, and Laboratory
Services, Centers for Disease Control and
Prevention Atlanta, GA, USA,
2
Division of
Adult and Community Health, National
Center for Chronic Disease Prevention and
Health Promotion, Ofce of
Noncommunicable Diseases, Injury and
Environmental Health, Centers for Disease
Control and Prevention Atlanta, GA, USA.
Key words: adults; anxiety; Behavioral Risk
Factor Surveillance System; depression; oral
health; population based; psychiatric
disorders; surveillance
Catherine A. Okoro, Division of Behavioral
Surveillance, Public Health Surveillance
Program Ofce, Ofce of Surveillance,
Epidemiology, and Laboratory Services,
Centers for Disease Control and Prevention,
1600 Clifton Road NE, MS E-97, Atlanta, GA
30333, USA
Tel.: +1 404 498 0504
Fax: +1 404 498 0585
e-mail: Cokoro@cdc.gov
Disclaimer: The ndings and conclusions in
this article are those of the authors and do
not necessarily represent the ofcial position
of the Centers for Disease Control and
Prevention.
Submitted 13 October 2010;
accepted 22 July 2011
134 doi: 10.1111/j.1600-0528.2011.00637.x
lence of a mental health disorder is 26% (7% for a
major depressive disorder and 18% for an anxiety
disorder) (3). In the United States, mental health
disorders consume substantial economic resources
each year; an estimated $150 billion annually, $71
billion in direct costs and $79 billion in indirect
costs (4). Nevertheless, while mental health disor-
der severity is strongly tied to treatment, one- to
two-thirds of serious disorders remain untreated
each year (5).
The U.S. Surgeon Generals (1) report on mental
health highlighted research that showed that mental
health is associatedwith physical health and general
well-being. Studies have documented an association
between mental health disorders and adverse health
behaviours, chronic disease, obesity, inadequate
social support and a poor health-related quality of
life (69). Several studies have not found a lower
likelihood of preventive health services use (10, 11)
or receiving routine health care in the past 5 years
(12) among persons with mental health disorders
compared with those without. However, other
studies have found modest associations for not
seeking preventive health care screenings among
persons with depressive disorders (13, 14).
Relatively, few studies have examined the rela-
tionship between use of oral health services and
mental health disorders; and those that have, have
had mixed results. Anttila et al. (15) found an
association between depression and fewer dental
visits among Northern Finlands 1966 Birth Cohort
(i.e., 3132 year olds), but did not have similar
ndings for persons with anxiety symptoms. In a
Northern Finland population-based study of men
and women aged 55 years, women with depressive
symptoms reported a longer time since their last
dental visit compared with those without depres-
sive symptoms, while depressive symptoms in
nonsmoking men were associated with edentu-
lousness (16). Conversely, in a multivariate analy-
sis of 388 Portuguese health science students (mean
age 21; 75% women), students who were anxious
were more likely to have visited a dentist in the
past year than those who were not anxious (17).
Studies have also found an association between
depression and periodontal disease, possibly be-
cause of behavioural and physiologic mechanisms
(1821). For example, Genco et al. (19) reported
that psychosocial measures of stress (e.g., nancial
strain) that manifest as depression are signicantly
associated with periodontal disease, as measured
by clinical attachment loss or alveolar bone loss.
However, other studies have found no association
between depression and periodontal disease or
tooth loss or have had mixed results (16, 22). In
addition, studies have reported an association
between depressive symptoms and higher lactoba-
cillus counts that may contribute to an increased
risk for dental caries among persons with depres-
sion (23, 24). For example, certain characteristics
associated with depression may support the
growth of lactobacilli, such as diet, oral health
behaviour and disorders of the endocrine and
monoamine regulatory mechanisms (23). In addi-
tion, saliva assists in preventing bacterial adher-
ence to tissues and some of these factors may
adversely affect salivary secretion. Among persons
being treated for depression, the use of antidepres-
sant medication has been associated with an
increased risk for dental caries as well (15, 23, 25
27). For example, some antidepressant medications
may reduce salivary secretion and thus, encourage
the growth of lactobacilli which may lead to
increased dental caries (15, 23, 2527). Other oral
health-related side effects of antidepressant medi-
cations include xerostomia, dysgeusia and bruxism
(24, 27).
Given that an estimated one in ve dental
patients may have a depressive disorder (24) as
well as the early onset and high prevalence of these
disorders, developing evidence-based primary and
secondary prevention strategies are essential. The
results from this study will add to the research base
and inform public health professionals and dental
health professionals decision making on effective
interventions to identify and address depression
and anxiety disorders during the provision of oral
health care. Nonetheless, it should be noted that
our study uses 2008 Behavioral Risk Factor Sur-
veillance System (BRFSS) cross-sectional survey
data to examine whether depression and anxiety
and the use of oral health services and tooth loss
are related; and thus, cannot determine the direc-
tionality of these relationships. Specically, our
study aims to examine whether associations exist
between depression and anxiety and use of oral
health services and tooth loss after taking into
consideration potential confounders.
Materials and methods
The BRFSS is a state-based surveillance system
that is operated by state health departments in
collaboration with the U.S. Centers for Disease
Control and Prevention (CDC). A detailed descrip-
135
Depression and anxiety and oral health
tion of the survey methods is available elsewhere
(28). Briey, the surveillance system collects data
on many of the behaviours and conditions that
place adults (aged 18 years) at risk for chronic
disease (29, 30). Trained interviewers collect data
monthly by using an independent probability
sample of households with telephones among the
noninstitutionalized U.S. adult population. The
data from each state are weighted to reect the
respondents probability of selection and the age-
and sex-specic or race ethnicity-, age- and sex-
specic population of the state. Representative
state estimates are then aggregated. All BRFSS
questionnaires and data are available at http://
www.cdc.gov/brfss.
In 2008, 16 states administered the optional BRFSS
Anxiety and Depression Module (ADM): Arizona,
Colorado, Hawaii, Idaho, Illinois, Kansas, Louisi-
ana, Maine, Massachusetts, Mississippi, Nebraska,
New York, North Dakota, Ohio, Vermont and
Washington. Therefore, the analyses are limited to
data from those 16 states. Based on Council of
American Survey and Research Organizations
(CASRO) guidelines, the median response rate for
the 16 states that used the ADM was 49.9% and
ranged from 40.0% in New York to 65.5% in
Nebraska (31). Similar to other telephone surveys,
a number of factors have impacted the BRFSS
CASRO response rate: such as a decreased number
of households with landline telephones an esti-
mated 18.9% of households had only wireless
telephones in 2008 (32); increasedtelephone number
portability; and advancements in telephone tech-
nologies (e.g., answering machines, caller ID, voice-
mail) (33). These factors may potentially introduce
noncoverage bias. However, researchers have found
that estimates derived from the BRFSS are compa-
rable to other U.S. population surveys (34, 35).
The BRFSS ADM consists of 10 questions,
including the Patient Health Questionnaire 8
(PHQ-8) (36). The PHQ-8 is adapted from the 9-
item scale (i.e. PHQ-9) (36, 37), which is based on
nine criteria on which the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (38)
diagnosis of depressive disorders is based. The
9th criterion was omitted because it assesses
suicidal or self-injurious ideation, and adequate
intervention could not be conducted over the
telephone. The PHQ-8 has comparable sensitivity
and specicity to other depression measures and
requires less time to administer (6, 36, 37).
We used the PHQ-8 to estimate the prevalence of
current depressive symptoms. The PHQ-8 response
set was standardized to be similar to other BRFSS
questions by asking the number of days in the past
2 weeks the individual experienced a particular
depressive symptom (Online Appendix). The mod-
ied response set was converted back to the
original PHQ-8 response set: 01 day = not at
all; 26 days = several days; 711 days = more
than half the days; and 1214 days = nearly every
day, with points (03) assigned to each category,
respectively. The scores for each item were
summed to produce a total score between 0 and
24 points. A total score of 04 represented no
signicant depressive symptoms; a total score of 5
9 represented mild symptoms, 1014 represented
moderate symptoms, 1519 represented moder-
ately severe symptoms and 2024 represented
severe symptoms (36). Respondents were consid-
ered to have current depressive symptoms (i.e. past
2 weeks) if their total score was 10, which has an
88% sensitivity and specicity for major depression
(36, 37).
Lifetime diagnoses of a depressive or an anxiety
disorder by a healthcare professional was assessed
with the remaining two questions of the ADM:
Has a doctor or other healthcare provider EVER
told you that you had a depressive disorder
(including depression, major depression, dysthy-
mia or minor depression)? and Has a doctor or
other healthcare provider EVER told you that you
had an anxiety disorder (including acute stress
disorder, anxiety, generalized anxiety disorder,
obsessive-compulsive disorder, panic disorder,
phobia, post-traumatic stress disorder or social
anxiety disorder)?
Three questions were used to determine survey
participants use of oral health services and tooth
loss. Specically, BRFSS respondents were asked:
(1) How long has it been since you last visited a
dentist or a dental clinic for any reason?, (2) How
many of your permanent teeth have been removed
because of tooth decay or gum disease? Include
teeth lost to infection, but do not include teeth lost
for other reasons, such as injury or orthodontics
and (3) How long has it been since you had your
teeth cleaned by a dentist or dental hygienist?
Instructions were given to interviewers to include
wisdom tooth loss because of tooth decay or gum
disease (i.e. infection). Predened tooth loss
response categories were as follows: none, 15, 6
or more but not all, and all. Respondents who
reported never having visited a dentist or having
all their permanent teeth removed were not asked
how long it had been since they had their teeth
136
Okoro et al.
cleaned by a dentist or dental hygienist. Based on
these questions, receipt of oral health services (i.e.
dental visit or cleaning visit or both <1 year ago
versus 1 or more years ago or never) and tooth loss
were assessed.
The demographic variables in our analyses
included respondents age (1834, 3544, 4554,
5564, 6574 and 75), sex, race ethnicity (non-
Hispanic white, non-Hispanic black, Hispanic and
other), education (less than high school diploma,
high school graduate or GED, some college and
college graduate), employment (employed, unem-
ployed, homemaker or student, retired and unable
to work) and marital status (married, divorced or
separated, widowed and never married or member
of an unmarried couple). In addition to demo-
graphics, ve chronic health conditions, including
angina pectoris, myocardial infarction, stroke, dia-
betes and asthma were assessed by asking respon-
dents whether they had ever been told by a doctor
or other health professional that they had these
conditions.
All respondents were asked their height and
weight and about their cigarette smoking habits,
alcohol consumption, use of assistive technology
and perceived level of social and emotional sup-
port. Respondents body mass index [BMI =
weight in kilograms (kg) divided by the square of
height in meters (m
2
)] was determined from self-
reported height and weight. Respondents were
classied as underweight (<18.5), normal weight
(18.5 to <25), overweight (25 to <30) and obese
(30). Respondents cigarette smoking status was
determined by two questions: (1) Have you
smoked at least 100 cigarettes in your entire life?
and (2) Do you now smoke cigarettes every day,
some days, or not at all? Based on their responses,
respondents were placed in one of four categories.
Respondents who reported that they had not
smoked 100 cigarettes in their lifetimes were
dened as never smokers. Those who responded
in the afrmative for having smoked 100 cigarettes
in their lifetimes and who also said that they do not
smoke at all now were dened as former smokers.
Respondents who reported ever smoking 100
cigarettes and responded that they now smoke
some days or every day were classied as current
smokers. Heavy drinkers were dened as men
who reported drinking more than two drinks per
day and as women who reported drinking more
than one drink per day (39). Respondents use of
assistive technology was based on the question: Do
you now have any health problem that requires
you to use special equipment, such as a cane, a
wheelchair, a special bed, or a special telephone?
Perceived level of social support was assessed with
the question, How often do you get the social and
emotional support that you need? Possible re-
sponses were grouped into three categories: (i)
always or usually, (ii) sometimes and (iii) rarely or
never.
Statistical analyses
We used SAS and SAS-callable SUDAAN in all
analyses to account for the complex survey design
(40, 41). Crude (unadjusted) prevalence estimates,
adjusted predicted marginals and adjusted preva-
lence ratios (APRs) and 95% condence intervals
(CIs) were obtained using the MULTILOG proce-
dure in SUDAAN (41). Specically, we used
binomial logistic regression analysis to estimate
predicted marginals and APRs for each outcome
variable [i.e. use of oral health services (dental
and or cleaning visit in the past year versus
1 years ago or never) and tooth loss (none versus
1 teeth removed)] in association with each inde-
pendent variable (i.e. current depression, lifetime
diagnosed depression and lifetime diagnosed anx-
iety; referent = absence of disorder) after adjust-
ment for multiple confounders. We used
multinomial logistic regression analysis to estimate
adjusted odd ratios (AORs) for tooth loss [i.e. 0 (the
referent group), 15, 631, and all] in association
with each independent variable, and to estimate
predicted marginals and APRs by level of tooth
loss (i.e. 0, 15, 631 and all) in association with
each independent variable. We tested the propor-
tional odds assumption of cumulative logit using
the SURVEYLOGISTIC procedure in SAS (40). The
proportional odds assumption was invalid for our
models (i.e. Score tests: P < 0.001); therefore, multi-
nomial logistic regression analysis rather than
ordinal logistic regression analysis was used. For
each outcome of interest, we tested interactions
between sex and age group with each independent
variable and found them to be nonsignicant with
one exception for tooth loss, the interaction term
for lifetime diagnosed depression and age group
had borderline signicance (P = 0.0525). For all
analyses, P values <0.05 were considered signi-
cant. Eight states Colorado, Kansas, Maine,
Massachusetts, Nebraska, New York, Ohio and
Washington collected the ADM on a subset of
their respective states sample. Information on the
weighting methodology and the weights to use for
each of these states can be found at http://
137
Depression and anxiety and oral health
www.cdc.gov/brfss/technical_infodata/surveyda-
ta/2008/2008_multiple.htm.
Results
Of the total 96 223 respondents, we excluded those
with unknown status for receipt of oral health
services and tooth loss (n = 2129), those with
unknown status for depression and anxiety
(n = 11 028) and those with missing data on
demographics (n = 2580). Respondents excluded
from the study population were more likely than
those included to be aged 65 years or older, non-
white, not currently married, not currently em-
ployed and not to have higher than a high school
education (P < 0.0001 for all). There was no
difference in study inclusion by sex (P = 0.5545).
Table 1 presents the characteristics of the nal
analytic sample (n = 80 486). Among the respon-
dents included in our analyses, 8.1% [standard
error (SE), 0.2%] had current depression, 16.0%
(SE, 0.3%) had a lifetime diagnosis of depression
and 12.3% (SE, 0.2%) had a lifetime diagnosis of
anxiety.
Use of oral health services
Overall, 73.1% (SE, 0.3%) of adults used oral
health services in the past year. Among adults, the
unadjusted prevalence of nonuse of oral health
services in the past year was signicantly higher
among those with current depression, lifetime
diagnosed depression and lifetime diagnosed
anxiety than those without each disorder, respec-
tively (P < 0.001 for all) (Table 2). After adjust-
ment for sociodemographic characteristics (age,
sex, race ethnicity, education, marital status
and employment status), adults with current
depression and lifetime diagnosed depression
were 1.38 (95% CI = 1.281.49) and 1.15 (95%
CI = 1.081.22) times as likely not to have had a
dental or cleaning visit in the past year than those
without each of these disorders (Table 2, Model
1). After further adjustment for adverse health
behaviours, comorbid conditions, BMI, and use of
assistive technology, the association between non-
use of oral health services and current depression
remained signicant; however, for adults with
lifetime diagnosed depression, the association
attenuated and was no longer signicant (Table 2,
Model 2). After further adjustment for perceived
social support, adults with current depression
remained signicantly more likely to have not
used oral health services in the past year (Table 2,
Model 3).
Tooth loss as a dichotomous outcome
Overall, 56.1% (SE, 0.4%) of adults had no tooth
loss, 29.6% (SE, 0.3%) had 15 missing teeth, 9.7%
(SE, 0.2%) had 631 missing teeth and 4.6% (SE,
0.1%) had total tooth loss. The unadjusted preva-
lence of having at least one tooth removed differed
signicantly by current depression status, lifetime
diagnosed depression and lifetime diagnosed anx-
iety (P < 0.001 for all) (Table 3). Among adults,
after adjustment for sociodemographic characteris-
tics and use of oral health services, those with
current depression, lifetime diagnosed depression
and lifetime diagnosed anxiety were signicantly
more likely to have had at least one tooth removed
than those without each of these disorders (Table 3,
Model 1). After fully adjusting for all evaluated
confounders, these associations remained signi-
cant (Table 3, Model 3).
Tooth loss as a nominal outcome
Table 4 presents the unadjusted and AORs of the
multinomial logistic regression analysis for depres-
sion and anxiety by level of tooth loss. Among
adults, the unadjusted results indicate that each of
these conditions were associated with an increased
likelihood of tooth removal compared with no
tooth removal. After adjusting for sociodemo-
graphic characteristics and use of oral health
services, the estimated odds of being in the 631
teeth removed versus 0 teeth removed categories
was almost tripled (AOR = 2.89; 95% CI = 2.43
3.44) for those with current depression versus those
without (Table 4, Model 1). The estimated odds of
being in the 15 teeth removed or all teeth removed
categories versus 0 teeth removed category were
signicantly increased as well for those with
current depression versus those without. After
fully adjusting for all evaluated confounders, these
odds were attenuated but remained signicant
(Table 4, Model 3). For both lifetime diagnosed
depression and anxiety, after fully adjusting for all
evaluated confounders, the estimated odds of
being in the 15 teeth removed or 631 teeth
removed categories versus 0 teeth removed cate-
gory were attenuated but remained signicant
(Table 4, Model 3).
We also used generalized multinomial logistic
regression analysis to obtain predicted marginals
and APRs for each level of tooth loss (i.e. 0, 15,
631 and all) for depression and anxiety. After
138
Okoro et al.
Table 1. Characteristics of the study population
a
, Behavioral Risk Factor Surveillance System 2008
Characteristic n N %
Age (years)
1834 9988 15 068 245 27.5
3544 12 698 11 989 760 21.9
4554 17 637 10 924 402 20.0
5564 17 849 8 035 916 14.7
6574 12 664 4 700 201 8.6
75 9650 3 993 087 7.3
Sex
Male 30 599 26 447 083 48.3
Female 49 877 28 264 529 51.7
Race ethnicity
White, non-Hispanic 65 787 42 192 944 77.1
Black, non-Hispanic 4550 4 516 360 8.3
Hispanic 4208 4 783 203 8.7
Other, non-Hispanic
b
5941 3 219 104 5.9
Education
<High school 6091 4 289 949 7.8
High school 22 719 15 166 117 27.7
Some college 22 246 14 702 957 26.9
College graduate 29 430 20 552 588 37.6
Marital status
Married 46 759 33 879 698 61.9
Divorced Separated 12 778 5 710 716 10.4
Widowed 9631 3 046 085 5.6
Never married unmarried couple 11 318 12 075 113 22.1
Employment
Employed 45 367 34 521 678 63.1
Unemployed 3074 3 018 903 5.5
Retired 20309 8 298 897 15.2
Homemaker student 7470 6 599 428 12.1
Unable to work 4266 2 272 706 4.2
Smoking status
Current smoker 12 805 9 703 948 17.8
Former smoker 24 079 14 113 765 25.9
Never smoker 43 351 30 713 837 56.3
Alcohol consumption
Heavy 4147 2 964 919 5.5
Moderate 37 033 27 475 950 51.0
None 38 134 23 396 808 43.5
Body mass index (kg m
2
)
<18.5 1308 1 009 618 1.9
18.5 to <25.0 27 978 19 579 311 36.9
25.0 to <30.0 28 080 18 911 753 35.7
30.0 20 413 13 520 469 25.5
Ever diagnosis of chronic disease
Angina pectoris 4520 2 281 684 4.2
Myocardial infarction 4365 2 122 331 3.9
Stroke 2808 1 302 178 2.4
Diabetes 8497 4 383 255 8.0
Asthma 10 529 7 380 831 13.5
Use assistive technology 7186 3 557 790 6.5
Social support
Always or usually 65 271 44 350 377 81.8
Sometimes 8597 6 107 455 11.3
Rarely or never 5807 3 727 542 6.9
n, unweighted sample size; N, population estimate; %, weighted percentage.
a
Aggregate of 16 states: Arizona, Colorado, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maine, Massachusetts,
Mississippi, Nebraska, New York, North Dakota, Ohio, Vermont, and Washington.
b
Other, non-Hispanic includes Asian, non-Hispanics; American Indian or Alaska Native, non-Hispanics; and Native
Hawaiian or other Pacic Islander, non-Hispanics.
139
Depression and anxiety and oral health
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140
Okoro et al.
adjusting for sociodemographic characteristics and
use of oral health services, adults with each of these
disorders were signicantly more likely to have 15
teeth removed and 631 teeth removed, and
signicantly less likely to have 0 teeth removed,
compared to those without each of these disorders
(data available upon request). After fully adjusting
for all evaluated confounders, these associations
attenuated but remained signicant, except for 15
teeth removed [30.8% versus 29.1% (P = 0.08); APR
= 1.06, 95% CI = 0.991.12] among adults with
lifetime diagnosed depression and 631 teeth
removed [10.5% versus 9.5% (P = 0.11); APR =
1.10, 95% CI = 0.981.23] among adults with
lifetime diagnosed anxiety.
Discussion
This study, to our knowledge, is the rst to inves-
tigate the associations of depression and anxiety
with the use of oral health services andtooth loss in a
large sample of U.S. community-dwelling adults.
Our results suggest that disparities in the prevalence
of use of oral health services and tooth loss exist
among persons with depression and anxiety. The
prevalence of nonuse of oral health services in the
past year was signicantly higher among adults
with current depression than those without this
disorder. In addition, adults without these mental
health disorders had a signicantly higher preva-
lence of not having any teeth removed because of
tooth decay or gum disease.
Adults with current depression were less likely to
have usedthe services of a dental healthprofessional
in the past year compared to those without this
disorder, even after adjustment for several con-
founding variables. Whereas, among adults with or
without lifetime diagnosed depression and anxiety,
there was no difference in use of dental services after
adjustment for confounding variables. These differ-
ing ndings may reect the oral health behavioural
consequences that occur among adults with current
depressive symptoms who have not yet been
screened for clinical depression, or, if diagnosed,
remainuntreatedor medically noncompliant (15, 16,
Table 4. Crude and adjusted odds ratios (AORs) between current depression and lifetime diagnosis of depression or
anxiety and level of tooth loss among U.S. adults aged 18 years, Behavioral Risk Factor Surveillance System, 2008
Current
depression
a
Lifetime diagnosis
of depression
b
Lifetime diagnosis
of anxiety
c
15 teeth versus 0 teeth removed
Crude OR (95% CI) 1.58 (1.401.80) 1.24 (1.141.36) 1.25 (1.131.38)
AOR 1 (95% CI) 1.65 (1.431.91) 1.27 (1.151.40) 1.37 (1.221.53)
AOR 2 (95% CI) 1.44 (1.231.69) 1.16 (1.041.28) 1.26 (1.121.42)
AOR 3 (95% CI) 1.35 (1.141.59) 1.13 (1.021.26) 1.23 (1.091.39)
631 teeth versus 0 teeth removed
Crude OR (95% CI) 2.86 (2.483.29) 1.75 (1.581.95) 1.54 (1.351.75)
AOR 1 (95% CI) 2.89 (2.433.44) 1.67 (1.471.89) 1.64 (1.411.90)
AOR 2 (95% CI) 2.04 (1.692.45) 1.33 (1.161.53) 1.32 (1.121.56)
AOR 3 (95% CI) 1.83 (1.512.22) 1.27 (1.101.47) 1.27 (1.071.50)
All versus 0 teeth removed
Crude OR (95% CI) 2.42 (2.032.88) 1.40 (1.221.61) 1.37 (1.171.60)
AOR 1 (95% CI) 2.15 (1.702.72) 1.26 (1.061.50) 1.49 (1.221.82)
AOR 2 (95% CI) 1.58 (1.232.03) 0.96 (0.791.16) 1.18 (0.951.47)
AOR 3 (95% CI) 1.44 (1.111.86) 0.93 (0.761.13) 1.14 (0.911.43)
OR, odds ratio; CI, condence interval.
AOR 1: Adjusted for age, race ethnicity, marital status, employment status and dental visit or cleaning (<12,
12 months).
AOR 2: Model 1 plus additional adjustment for smoking status (current, former, never), alcohol consumption [heavy
(males >2 day, females >1 day), moderate, none], body mass index (<18.5 kg m
2
, 18.5 to <25.0, 25.0 to <30.0, and 30.0),
angina pectoris, myocardial infarction, stroke, diabetes, asthma and use of assistive technology.
AOR 3: Model 2 plus additional adjustment for perceived social support (always or usually; sometimes; and rarely or
never).
a
Comparing adults with 0 teeth removed without current depression to each tooth loss category (15, 631 and all)
among those with current depression.
b
Comparing adults with 0 teeth removed without a lifetime diagnosis of depression to each tooth loss category (15, 631
and all) among those with a lifetime diagnosis of depression.
c
Comparing adults with 0 teeth removed without a lifetime diagnosis of anxiety to each tooth loss category (15, 631
and all) among those with a lifetime diagnosis of anxiety.
141
Depression and anxiety and oral health
27, 42). Indeed, many of the depressive symptoms
identiedwiththe BRFSS PHQ-8 (Online Appendix)
may adversely affect adults oral health behaviours,
such as lack of motivation, feelings of worthlessness
and fatigue (36, 37). Conversely, adults with lifetime
diagnosed depression or anxiety may have received
treatment for these disorders and, thus, be better
equipped and supported to manage their oral
healthcare needs. Further research is needed to
elucidate the role mental health treatment and
disease management plays in the associations
among depression and anxiety, use of oral health
services and periodontal health.
The results of this study are consistent with
ndings of previous studies that linked depressive
disorders to a decreased frequency of oral health
check-ups and an increased risk of periodontal
disease and or tooth loss (15, 19, 20). For example,
Genco et al. (19) found that, in a cross-sectional
study of 25- to 74-year-old persons in Erie County,
New York, depression was associated with greater
levels of periodontal disease. Monteiro da Silva
et al. (20) reported that both depression and lone-
liness were associated with adult onset of rapidly
progressive periodontitis. Anttila et al. (15) re-
ported that, in a Northern Finland cohort of
persons born in 1966, depressive symptoms were
associated both with a lower frequency of tooth
brushing and with dental checkups.
Research has been inconsistent regarding the
association between dental health behaviours and
lifetime diagnosed anxiety. Anttila et al. (15)
found that anxiety symptoms were signicantly
associated with lower tooth brushing frequency
and self-perceived need of dental treatment but
were not associated with frequency of dental
visits. In addition, studies have reported an
association between dental anxiety a different
anxiety disorder, although associated with general
anxiety (43, 44) and poor oral health and
avoidance of oral health services (4547). How-
ever, we were unable to explore the impact of
dental anxiety on the association between lifetime
diagnosed anxiety and use of oral health services
in this study.
Our study is subject to several limitations. First,
all data including oral health services, tooth loss,
mental health disorders and confounders are self-
reported. Thus, these data are subject to recall and
social desirability biases and have not been vali-
dated. Second, although we have adjusted for
several confounders in our analyses, we were
unable to examine other factors associated with
use of oral health services or tooth loss, such as
dental insurance, dental caries, periodontal disease,
daily hygiene routines, community water uorida-
tion, dentures or antidepressant medications.
Third, non-Hispanic minorities, as well as persons
aged 65 years or older, with less than a college
education, widowed, retired and unable to work,
were less likely to be included in the analysis. As
many of these demographic characteristics are
associated with the nonuse of oral health services,
tooth loss and depression and anxiety, the effect on
our ndings is not known but, likely, resulted in
more conservative estimates. Fourth, our study was
cross-sectional. Thus, we cannot infer causality. In
fact, the relationship between mental health disor-
ders and the use of oral health services and tooth
loss may be bidirectional. Mental health alone may
affect oral health, physical health, health behav-
iours, self-management of disease, medical com-
pliance, social interactions and quality of life (1,
48). Coexisting with poor oral health or other
chronic conditions, mental health disorders con-
tribute to severity and progression of disease and
poorer outcomes (49). In addition, the use of
antidepressant medications among people with
depression or other mental illness may contribute
to oral health disease, as increased lactobacillus
counts, xerostomia, dysgeusia and bruxism are
common side effects of psychotropic medication
(15, 2426). Conversely, persons with infrequent
dental care and or tooth loss may have a lower
socioeconomic status, have lower self-esteem, have
inadequate social support, lack access to oral health
services, practice other health-compromising
behaviours or have other health conditions that
require greater resources and management. These
factors may lead to depression, and compounded,
contribute to the severity of depression as well.
In the United States, mental health is on the public
health agenda as an integral component of health
(1). In recognition of the intertwined relationship of
physical health, mental health and social well-being,
oral health must not be forgotten. Indeed, it is an
essential component of overall health and well-
being (48, 49). Our ndings underscore an associa-
tion between depression and anxiety and the use of
oral health services and tooth loss. These ndings
have even stronger implications because rst onset
for many psychiatric disorders occur early in the life
course (2), increasing their potential to negatively
impact oral health over time. Longitudinal studies
are needed to assess depression and anxiety disor-
ders oral health impact.
142
Okoro et al.
To compound the issue of inadequate mental
health treatment among persons with depression
and anxiety (5), many of the psychotropic medica-
tions used to treat these disorders can increase the
risk of dental disease (15, 2326). In recognition of
this as well as the interrelationship between mental
and physical health, mental health professionals
should encourage their patients to visit both
primary healthcare professionals and dental
healthcare professionals to obtain preventive ser-
vices and medical and oral health care. Moreover, it
is vital to inform persons that they should report all
health conditions (both mental and physical) and
prescription drug usage when providing medical
history to dental healthcare professionals.
Acknowledgement
We thank the state BRFSS coordinators for their partic-
ipation in data collection for this analysis and the
Behavioral Surveillance Division staff for their assistance
in developing the database.
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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. BRFSS Patient Health Questionnaire 8
(PHQ-8)
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